Use of Wagner cementless self-locking stems for massive bone loss in hip arthroplasty

Transcription

1 lournal dozthpidic Sugery 2003: 11 (1): xxx-xxx Use of Wagner cementless self-locking stems for massive bone loss in hip arthroplasty -4- Buddhist Tzu-Chi Dalin General Hospital, Chiayi, Taiwan INTRODUCTION a ABSTRACT Purpose. To assess the use of Wagner cemendess df- locking stems for massive bone loss in hip hplasty. Patients and methods. 22 patients with severe pdmal femoral bone loss either due to prosthetic loosening or comminuted fracture were treated by Wagner cementless self-locking revision stems between November 1993 and June Results. Radiographic evidence of early bony incorporation was found by 1 month in most cases. At a mean follow-up of 7.1 years, the mean Harris hip score increasedfrwn30to84points Itwaslessthan80points in 4 patients, *of whom experienced severe thigh pain due to marked progressive subsidence of the stems (by 13 mm and 20 mm), which were revised 2 and 3 years later respectively. Conclusion. Implantation of a Wagner cementless selflocking revision stem provided satisfactory results for 82% of patienfs. Hence, in some difficult conditions, this device is a good choice of management. Key words: arthroplasty, replacement, hip; transfemoral approach; Wagner stem Hip artimplasty is sometimes very difficult when the proximal femur has been destroyed-for example, huse of extensive bone resorption in revision cases, an unstable stem after fractures, or severe comminuted fracture. To solve this problem, cementing1 autogenous bone grafting,2 massive allograft bone packingm cortical strut grafting,6 and use of various uncemented long-stem and have been tried, achieving variable results. The concept of stem fixation has been developed by Wagner,=I4 with the emphasis on fixation by the distal femur to spa the diseased part of the pmximal femur, thereby allowing the latter to heal. This approach has been adopted by some surgeons within the field of revisional total hip arthropla~ty.~~ We have expanded the indications to include some unstable peritrochteric fractures that ace difficult to treat or that have failed reduction and fixation; the results are promising and encouraging, and are reported in this paper. Address compondence and reprint requests to: Dr Shaw-Ruey Lyu, Chief, The Joint Center, Buddhist Tzu-Chi Dalin General Hospital, No 2, Min-Shen Road, Dalin, Chiayi, Taiwan. srlyu@seed.net.tw

2 Vol. 1 1 No. 1, June 2003 Use of Wagner cementless self-locking stems for hip arthroplasty 109 PATIENTS AND METHODS From November 1993 to June 1995, we implanted 22 Wagner stems (Wagner SL revision stem; Protek AG, Bern, Switzerland) in 22 patients. The stem is made of a high-strength titanium-aluminium-niobium alloy and has a dull corundum-blasted finish The main part of the stem is conically shaped and has 8 longitudinal ribs to provide rotational stability (Fig. 1). The conical shape of the prosthesis allows spontaneous selfstabilisation in case of microscopic bone resorption. The prosthesis automatically adapts to the conformation of the new surroundings by settling further into the medullary cavity postoperatively. The patients were 8 men and 14 women whose average age at the time of arthroplasty was 64 years (range, years). The preoperative diagnosis of these patients were unstable comminuted fradure of proximal femur in 8 hips (in patients who could not Figure 1 The Wagner stem. - Table ratlent characteristics slslsiayrrarrrcopartive Hawiship cae 1 6(YM RwipmshtiC. 265A7 bur" /97 (96) 2 60/F Loasen% 22W5 YIS* /90 (95) 3 59/F CommnW YIS (93) 4 53n= ~00sen 2 25 ~ YIS (92) 5 67lM Communiled 19M5 Y/S DembitusM 11 36/88(91) 6 59/M I n W 22W6 Yll (91) 7 76E Loosen YIS 1.2 la 10 3W85 (89) 8 53/F Lamm 19WI5 Y /87(88) 9 61/F L m 265A 6 NIT Subsii00 mmw 16 19/29 (87) 10 65M Commurited Y/S DimnM 8 23/82 (86) 11 67/F Communited YIS (85) 12 70/M Petiprmdretic 2W17 Nrr /87 (84) 13 67ff Locxen 22Y14 N/T W91 (83) 14 72E Loosen 22W 5 YE 1.O /86 (83) 15 65A Communiled 19W4 YIS /89 (82) 16 6UM Idecled 265/17 W Subsidence (13 mmw 14 28/63 (81) 17 7l/F Looren 2W15 YIS Q195(80) 18 58/M Communited YIS /86 (80) F Lmsen 22W 4 YIT /94 (79) 20 6M Communid YIS /91 (78) 21 65/M Communibed 19O/l6 YIS /87 (78) 22 74/F Loosen 22W5 YIS Subsidence (10 mmyn 8 34/69 (77) Type II periprosthetic (cemented) fracture ' Loosening of previous implant with type II proximal femoral defect * Difficult comminuted fracture of proximal femur -' Infected loosening of previous implant I T transfernoral approach ' S standard antwolateral approad

3 110 SRLyu lournal oi Orthopaedic Surgery withstand the long recovery time and uncertain results of reduction and fixation), aseptic loosening in 10 hips (loosen primary total hip arthroplasty in 6 hips; loosen revisional total hip arthroplasty in 4 hips), septic loosening of primary total hip arthroplasty in 2 hips, and femoral fracture after primary total hip arthroplasty in 2 hips. The preoperative Harris hip score was below 50 in all cases. All hips had the same problem of marked damage of the proximal femur, which would not have provided a good base for the initial Fixation of most available stems (Table). The standard anterior-lateral surgical approach without trochanteric osteotomy was used in most cases. For the 8 patients with peritrochanteric fracture, the femoral neck was osteotomised at an appropriate level, and the remaining bony fragment together with fractured fragments were preserved for later reduction during and after the impaction of the stem. in 5 cases of revision, the transfemoral approach described by Wagner'3,'%as used to remove the cemented old implant When performing the transfemoral approach, the proximal medullary cavity was curretaged to healthy bone, which was confirmed by the active oozing of blood. The myofascial attachment of the proximal bony fragments was well preserved throughout the procedure. The distal femoral canal was prepared by using an appropriately sized reamer to receive the prosthesis with a snug fit. No attempt was made to rigidly h the damaged proximal femoral fragments to the prosthesis. Only absorbable suture materials were used to fix the myofasciau and d o n v framents together. Bone grafting was used in one case, because the bone stock of the femoral canal had become poor from previous failed revisions. We used an impacted allograft to fill the gap to provide a snug fit for the largest prosthesis available. Postoperatively, the rehabilitation protocols were tailored to fit the individuals. As a general rule, gentle passive range of motion was allowed for 2 weeks to facilitate soft tissue healing; limited assisted active range of motion was then started, with care taken not to jeopardise the myofasciai- and osseousbony envelope of the proximal femur. Partial weightbearing and ambulation with 2 crutches were allowed in most cases when a snug fit of the prosthesis could be achieved during surgery. Non-weightbearing for 3 months was prescribed for the single case of allografting. Patients were regularly followed up-at 6 weeks, 3 months, 6 months, 1 year and then once a year. Follow-up examinations included radiographic evaluation and physical examination with grading of pain, walking ability, and joint motion. The Harris hip scoring system was used for functional evaluation. RESULTS When only the stem was revised (4 cases), the average duration of surgery was 2.2 hours (range, hours) and the perioperative blood loss was 0.6 L (range, L). In 18 cases in which the acetabular component was also revised, the average duration of the operation was 2.8 hours (ranee hod and ~igure 2 he osteotomy site (a) before operation, (b) after operation, (c) 6 weeks postoperatively, and (d) 6 years postoperatively. Bony incorporation was found as early as 6 weeks after surgery.

4 Vol. 1 1 No. 1, lune 2003 Use of Wagner cementless self-locking stems for hip arthroplarty 1 1 I the average blood loss was 1.0 L (range, L). The mean total hospital stay was 1 days (range, 7-21 days). For patients who underwent procedures using the transfemoral approach (6 cases), the mean total hospital stay was 15 days (range, days). For the patients with unstable comminuted fracture of proximal femur fracture, the mean duration of surgery was 2.4 hours (range, hours), the mean blood loss was 0.7 L (range, L), and the mean total hospital stay was 10 days (range, 7-13 days) (Table). All but 2 patients regained their walking ability unaided within 3 months. Definite radiographic evidence of bone regeneration in the bony defects was achieved within 3 months in all patients except the recipient of the impacted allograft. For patients who underwent procedures using the transfemoral approach, bony incorporation of the osteotomy site was found as early as 6 weeks postoperatively (Fig. 2). At a mean follow-up of 7.1 years (range, years), the mean Harris hip score was 84 points (range, points). It was less than 80 points in 4 patients, 2 of whom aperienced severe thigh pain due to marked progressive subsidence of the stems (by 13 mm and 20 mm), which were revised 2 and 3 years later, using a larger femoral component DISCUSSION The primary goal of Wagner stem implantation is to make use of the fracturelike situation in the proximal femur, thereby keeping the fracture fragments well vascularised to stimulate new bone formation. The destructed upper femur, either caused by the disease * process itself or created by the procedure's transfemoral approach, heals quickly and well. Accordingly, the operative procedure can be simplified and the operative time shortened. The stem fixes rigidly to the isthmus of the femoral canal by way of its tapering shape. Rotational stability is also achieved by the specially designed ribs around the stem. Furthermore, the rigid initial stability allows the proximal femur to heal. Most of the cases in our series were revisions for failed sterns that could not be revised by conventional prosthesis because of massive bone loss in the proximal femur. Such condition is the original indication for the use of a Wagner stem. We have expanded this indication to elderly patients who had unstable comminuted proximal femoral fractures that were difficult to manage by reduction and fixation. We obtained favourable results in this pup of patients because of the relatively good bone quality in the femoral canal, which was important to bear the stem. The main reason for stem subsidence in our series was the poor quality of the bone due to multiple previous revisions or use of an undersized implant. This problem may be overcome by more careful selection of patients. In total hip arthroplasty, implantation of a Wagner stem is indicated when the proximal femur is destructed, usually with acceptable results. When using this stem, the proximal femur can be more easily manipulated (e-g. in the transfemoral approach) to facilitate difficult stem removal. The destructed bone heals quickly after this procedure, and the shortened operative time hdps with the rptum of functionality during immediate postoperative course. 1. Garcia-Cimbrelo E, Munuera L, Diez-Vazquez V. Long-term results of aseptic cemented Chamley revisions. J Arthroplasty 1995;10: Chao EY, Sim FH. Composite fixation of salvage prostheses for the hip and knee. Clin Orthop 1992;276: Gie GA, Linder L, Ling RS, Simon JP, SloaffT], Timperley A]. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1 993;75: Gustilo RB, Rstemak HS. Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop 1988;235: Rprosky WG, Bradford MS, Younger TI. Femoral reconstruction with massive allograft and cementless prosthesis. Chir Organi Mov 1994;79: Gross AE, Allan DG, Lavoie G], Oakeshott RD. Revision arthroplasty of the proximal femur using allograft bone. Ort)\op Clin North Am 1993;24: Grunig R, Morscher E, Ochsner PE. Three- to 7-year results with the uncemented SL femoral revision prosthesis. Arch Orthop Trauma Surg 1997;116: Eingartner C, Volkmann R, Putz M, Weller S. Uncemented revision stem for biological osteosynthesis in periprosthetic femoral fractures. Int Orthop 1 997;2 1 : Turner RH, Mattingly DA, Shller A. Femoral revision total hip arthroplasty using a long-stem femoral component. Clinical and radiographic analysis. J Arthroplasty 1987;2:

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